Review Question - QID 217253

This patient presents with asymptomatic, untreated hypertension in the setting of multiple prior documented instances of hypertension and adamantly refuses an appropriate, first-line medication for hypertension. The most appropriate response by the physician is to evaluate the patient’s understanding of his condition and the proposed medication.

Physicians should seek to use open-ended questions when soliciting patient history or the patient’s perspective of illness and its treatment. The tone should be open and non-judgmental, and the physician should not assume the patient’s intentions. While patients with decision-making capacity have the right to refuse treatment, physicians should seek to understand the patient’s perspective of their illness and understanding of the treatment (as well as its risks and benefits). This affords the physician the opportunity to correct any misconceptions that may be driving the patient’s decision. Approaching this conversation in an open and non-judgmental manner helps build the therapeutic alliance and foster physician-patient trust.

Incorrect Answers:
Answer 2: “Given your blood pressure, it is unlikely that it will resolve on its own with exercise” is inappropriate because while it is unlikely that this patient’s persistent hypertension will resolve with exercise alone, this assumes that the patient is refusing medication because he would like to treat with exercise alone. In contrast, the patient may be concerned about medication side effects or may not fully understand his diagnosis.

Answer 3: “Patients with untreated hypertension can often develop complications like kidney damage, heart failure, and stroke” is inappropriate because while these are recognized complications of hypertension, this statement does not seek to explore the patient’s understanding of his condition and treatment. It may be perceived as insensitive and also assumes that the patient does not already know these potential complications.

Answers 4: “Some patients do experience side effects from hydrochlorothiazide use. I can prescribe amlodipine instead” is inappropriate because it assumes the patient is concerned about medication side effects. The patient’s perspective and understanding should be elicited first.

Answer 5: “Why don’t we schedule a follow-up visit in 3 months to revisit this topic?” is inappropriate because the patient’s understanding of the condition and treatment should be elicited first. In addition to helping build the therapeutic alliance, this can help the physician correct any misconceptions the patient might have. Also, given his multiple elevated blood pressure readings, this patient’s hypertension is unlikely to self-resolve and should be treated to prevent further complications.

Bullet Summary:
When patients refuse treatment, the most appropriate next step is to evaluate the patient’s understanding of their condition and treatment using open-ended questions.